Moveable Mountains

Hey, guess what.

The strike due to begin today for all Kaiser Northern California mental health clinics has been called off! My dad emailed the good news from the East Coast  before I was even awake. You can read about the developments on the NUHW website.

I’ll be going on an extra long walk with my dog this morning to recover from the excitement of the last week.

Congratulations to all those Kaiser members with mental health and substance abuse challenges, their families and friends, their therapists, and NUHW’s superb staff, who have been working toward moments like this one for the last five years.

There’s still a long way to go, true. But the mountain just inched to the left.

Striking News

Tomorrow (Monday November 16, 2015) marks the kick-off of an open-ended strike by Northern California Kaiser’s mental health workers. To date the longest Kaiser therapist strike lasted a week, in January 2015. In previous strikes the message has been directed to the public through the media: “Here are the ways Kaiser patients are suffering as a result of Kaiser’s misbehavior.” This time the message is directed toward Kaiser executives: “We refuse to return to work until Kaiser comes up with a realistic plan to improve services and stops harrassing its employees.”

These particular 1400 Kaiser therapists have a lot of chutzpah. Kaiser may refuse to compromise, feeling  they have nothing to lose by waiting out the strikers. Unlike nursing strikes that cost Kaiser lots of money in wages paid to temporary workers, mental health strikes to this point only save Kaiser money. Historically, during therapist strikes Kaiser doesn’t hire temporary workers — the unkind word is “scab.” Instead they cut mental health services even further than their appalling baseline levels. Kaiser orders their psychiatrists (MD owners of Kaiser who don’t strike) and managers (who can’t strike) to cover emergency services and lets everything else fall by the wayside. Early evidence that this will be their primary stragegy is available on the union’s website. According to the NUHW, Kaiser has cancelled this week’s non-urgent appointments.

As in the past, Kaiser will be saving at least half a million dollars a day by not paying therapist wages while they’re on strike. It will only take eight working days to make back the $4 million in fines the Department of Managed Care forced Kaiser to pay for understaffing.

The NUHW is planning an opening rally on Monday in San Francisco at the Kaiser Medical Center, 2425 Geary Blvd, at 11AM. Former US Congressman Patrick Kennedy is going to be speaking. Since leaving Congress he’s been involved in developing mental health policy at the national level through the Kennedy Forum. Sonoma County Supervisor Shirlee Zane, whose husband Peter Kingston committed suicide while under the care of the Kaiser psychiatry department in Santa Rosa, will be speaking as well.

I’m doing my darndest to get myself and my client Chelsie in to San Francisco for the festivities (see Chelsie’s Story using the First 90 Days – Reader’s Edition tab on this website). Chelsie and I were interviewed by Fox News and included in last week’s 6PM news broadcast. That was exciting. (For my five seconds of fame I looked a little like Linus without his blanket — open parentheses around my eyes. Chelsie, however, looked fantastic and told her story well.)

I hope to see you at the rally. If we haven’t met, please introduce yourself. It’s so important to encourage each other through these experiences. Kaiser is changing. We know they are. But change is slow and people are struggling in the meantime. We need to give each other as many hugs as we can while we wait.

Won’t Ask, Won’t Tell

Last month I went to a suicide prevention seminar designed for therapists. In the first training video, a man who had jumped off the Golden Gate Bridge talked about his experience. For hours he was out in the wind trying to decide what to do. He told himself that if someone, anyone, asked him if he was OK, he wouldn’t jump. Eventually someone did stop to talk. But only to ask him to take her picture. He took this as his final sign.

The moment he cleared the railing he regretted his choice.

For chunks of the training I was dissociating. Words stopped penetrating. I felt floaty, detached. Dissociation is a natural process that kicks in when we’re overwhelmed. My body was shutting itself off from more input while my mind dealt with what was already on my plate. The same thing, dissociation, had happened to me only two times before — on the two occasions when I learned that a Kaiser client of mine had killed himself.

You might think it would be disturbing to dissociate in the middle of a training. But I knew what was happening. I knew I was safe, just overwhelmed by memories. Dissociation was a marker that I was in the right place addressing these issues. It proved that the suicides at Kaiser still bothered me years later, as one would expect, even hope. It motivated me to learn proven strategies to protect my current and future clients. I never again want to get news like that about someone under my care. Not if I can help it.

One of the stated goals of the training was to foster a willingness in therapists to conduct thorough suicide assessments. The need to foster willingness presumes that there are times when therapists are unwilling to ask about suicidal thoughts. Maybe the reason therapists avoid asking these difficult questions is that we don’t know what to do if our client says, “Yes, I am thinking of suicide. Yes, I do have a plan. Yes, tonight.”

To foster willingness, the seminar demonstrated that people with suicidal thoughts often respond to very basic interventions. Anyone can intervene just by opening up the conversation and focusing on safety planning. Consider the man on the bridge…. If a stranger had said, “How’s it going? Are you OK?” he would have said, “No. Actually I’m not OK.” And if the stranger had said, “Then let’s get off this damn bridge and talk for a little bit,” he would have gone with the stranger and talked. Someone who self-presents to a therapist, not a stranger, is even more likely to talk things through, to allow the therapist to make friends with the part of the client that wants to live, and to work collaboratively toward the client’s survival.

This training message worked for me. The very next day I started asking my clients at the health center where I now work, “When you get really down, how bad does it get? Do you think of suicide? Do you have a plan? Have you been having any of those thoughts recently?” I thank my clients for their honesty. I let them know that if suicidal thoughts emerge I want to know about them. There’s no need for anyone to sit alone with such loneliness.

I got into some very bad habits in my years at Kaiser. Perhaps the worst is that I learned not to ask too deeply about suicidal thoughts. I didn’t have time to manage a yes. To rationalize my avoidance I relied, as I’m sure my colleagues did and still do, on the questionnaire clients filled out every clinic visit. The questionnaire asks: “Over the last 2 weeks, how often have you been bothered by…thoughts you would be better off dead or of hurting yourself?” When clients responded with anything other than a “not at all,” I pursued. If they circled “not at all,” I left it alone. But, of course, there are many reasons why someone might not put in writing that they have suicidal thoughts. And only two reasons a therapist who cares about people would avoid repeating the question in person. The first was addressed by the training: not knowing what to do with a yes.

The second reason is not having enough time to manage a yes, even if you know what to do with one. At Kaiser, when I had only an hour to conduct an assessment of mental illness and develop a plan for follow-up, I was not going to open up a can as wormy as the one containing suicidal thoughts. Not if I could avoid it by rationalizing.

I’m just now undoing the far-reaching effects of working for seven years under such extreme time scarcity. Today there’s no can too wormy to explore. Because I have time to build relationship with my clients, at the clinic and in private practice, I can ask the hard, important questions. The training was all I needed to be reassured that I can handle a yes, that any of us can as long as we have time.

Barbara Ragan, who killed herself on July 5, 2015, by jumping from a Kaiser parking structure, had been for months telling her providers that she she needed help, that she was depressed and at risk of suicide. No one had the time to listen or to develop a plan for her safety. There are thousands of Kaiser patients every day who keep private their suicidal thoughts, hoping, like the man on the bridge, that their providers will ask, “How are you really doing?”

Kaiser therapists have announced their intent to launch a statewide open-ended strike. Soon they will leave their jobs and refuse to return until they are guaranteed adequate one-on-one time with their clients.Their message is the message of this post. If we have the time to listen, the man on the bridge will talk. He’ll even let us help him choose life.

But we have to have the time.

Not Enough Therapists? In California?

In an August 13, 2015 article by KHN’s Jenny Gold, the director of the Department of Managed Health Care, Shirley Rouillard, was quoted as saying: “There just aren’t enough therapists to see everyone who needs help. It isn’t just a plan problem; it’s a societal problem. And that is really the crux of the matter.”

Not enough therapists? Where is this assertion coming from? And why is it coming now, in this edgy interlude between the DMHC’s second report about Kaiser’s misbehavior and the announcement of remedy from the DMHC’s Office of Enforcement?

In a September 16, 2015 press release Kaiser’s public relations people claimed that: “Kaiser Permanente’s significant hiring of mental health therapists comes during an overall shortage of these professionals in the U.S. According to an April 2015 report by the National Alliance on Mental Illness (NAMI), patients nationwide face difficulties in finding a mental health treatment provider because of the increasing demand for, and shortage of, mental health professionals available.” I read the NAMI report in its entirety and did not find anything to suggest that urban areas in California have a shortage of therapists.

I find it alarming that the head of the agency responsible for holding Kaiser accountable to State mental health parity laws might be considering legitimate Kaiser’s cry of therapist shortages. Perhaps the distribution of therapists is not uniform across the United States. But there are more than enough therapists to meet the need in the urban areas where Kaiser primarily operates. A cursory search on the Psychology Today website in the California cities where Kaiser sees most of its patients reveals hundreds of licensed therapists in Oakland, San Francisco, Los Angeles, San Diego… to name a few of the cities where the DMHC has identified deficits in Kaiser’s care.

There are two main reasons why Kaiser continues failing to meet basic community standards of care. Neither has anything to do with a scarcity of therapists.

The first is that most therapists do not wish to work for an organization that makes it impossible to practice psychotherapy.  A friend at Kaiser’s Psychiatry Department in Santa Rosa confirmed that in the past year new hires, even though they’re being well paid right off the bat, are quitting their jobs quicker than their managers can replace them. Why? Because therapists want to help people. If we can’t see them, we can’t help them. Therapists will continue to quit or refuse new opportunities to work at Kaiser until Kaiser puts in place a credible plan to fix the problems now on the table.

A credible plan would include a statement of intent to improve and a time frame to make the improvements. For example, “By 2018, 95% of Kaiser members with mental health parity diagnoses will be receiving the level of care deemed appropriate by the therapists evaluating their needs.” A credible plan would include steps to achieve its goals, with visible measures for each step. But instead of a credible plan, with goals and strategies to achieve these goals, Kaiser claims they are diligently hiring more staff and that this single strategy will take care of the problems.

The second reason that Kaiser is failing to meet community standards for individual therapy is that they are not paying their subcontracted therapists enough. For the past year or so Kaiser has been subcontracting with a group called ValueOptions to manage their overflow. In Sonoma County (my home county) a Licensed Clinical Social Worker is offered $65 an hour to see a Kaiser patient through ValueOptions. By comparison Medicaid (MediCal in California) is paying LCSWs $103 an hour. Not surprisingly, the numbers of private practice therapists signing on to accept MediCal is growing geometrically whereas the numbers accepting ValueOptions/Kaiser remains low and the growth is flat.

If Kaiser wants to attract and retain new hires, they will need to present a realistic plan to transform the current structure into one that works for therapists and their clients. If they want to attract therapists in the community to participate as subcontractors in the care of Kaiser patients, ValueOptions will need to match Medicaid’s reimbursement rate.

Attention, DMHC: there is no shortage of therapists willing to take care of Kaiser patients with mental illness. Instead of accepting their clever excuses, this is the time to leverage Kaiser into making the real (and really expensive) changes they’re doing their darndest to avoid.


The following is a letter from a Kaiser member that was sent last week to US Senator Dianne Feinstein’s staffer Katie Gross and cc’d to me. The writer gave me permission to publish it and asked that her name be withheld. It reads…

I have been trying to get urgent mental health treatment at Kaiser Oakland for several months. Not only did I face blatant discrimination because I disclosed a history of depression and anxiety but I was insulted, discouraged and hounded with phone calls after I filed a grievance. I was told several times that Kaiser was “solution focused” and it was suggested that I take a vacation or join a gym. Kaiser called me several times a day for many weeks after my grievance. I thought they were calling me to give me the proper medical care, only to be aggressively asked to commit to not taking this issue any further by the Kaiser representative on the phone.

When calling member services I was told several times that “we know this is wrong and a problem and we agree with you.” I was encouraged by Kaiser employees to speak up for everybody. It was suggested several times that I present directly to the Kaiser offices and demand treatment. When I was finally approved for therapy I was referred to a company called Value Options which provided me with 5 phone numbers of outside providers. One of them called me back to say that Kaiser does not pay fair wages to see their clients and that she was not taking them into her practice. I have put in countless hours making complaints and have been met with disdain, judgement and discrimination. After months of complaining and tenacity I only now finally have what looks like a referral.

What is happening to patients that are suicidal or schizophrenic? Many mental health clients don’t have the will to fight against their illness and a system that denies their relevance or legitimacy. Please help us with this issue!! This needs to be addressed.

Thank you for any time and effort you can give.

It’s been seven months since the Department of Managed Health Care came out with their second report indicting Kaiser mental health services for insufficient care. In that February 2015 report, a panel of mental health professionals concluded that Northern California Kaiser mental health patients were waiting too long for initial or follow up appointments in 22% of the charts they reviewed. No fines have, as of yet, followed this stunning discovery. The DMHC’s first report, with less precise findings, was followed months later by a $4 million fine.

The above letter to Senator Feinstein, combined with recent conversations I’ve had with my colleagues at Kaiser in Santa Rosa, leads me to believe that adding contracted therapists through Value Options has done little if anything to address the problem. Waits between non-urgent appointments are still 4-6 weeks. The initial access process is still chaotic. People in need are still unable to get help. Only the very persistent and skilled are able to survive the front end of the system; the people who are most fragile and least articulate fall by the wayside.

I’ve decided to write a feature length article for our local independent newspaper, the North Bay Bohemian, as a way to raise awareness that change has stalled. I’ve already contacted the DMHC to pursue why no fines have followed their report and why progress toward parity has stalled. I’ll contact the Centers for Medicaid and Medicare Services (CMS) to ask why Medicare and Medicaid patients outside Kaiser receive appropriate mental health care, but the standards drop for Kaiser’s [Medicare] Advantage members and Kaiser MediCal (Medicaid) members.

In the meantime, anybody with recent experiences trying to get help for yourself or your family members, please continue to contact Katie Gross and cc me.

Closing the Loopholes

I just went on a lovely long walk with a friend of mine who still works at Kaiser’s Psychiatry Department in Santa Rosa. It was a lovely day. And she’s a lovely person. But it was an especially lovely trip because she told me about one particular change in charting policy, mandated by the Department of Managed Health Care (DMHC), that let me know those folks are on it. And not getting off it any time soon.

To summarize my previous post (Run DMHC!), in their latest report the DMHC indicated that they had conducted a review of 300 electronic medical records from 2012-2013. They employed a panel of experts to review these cases to assess if Kaiser is providing timely access to follow-up visits with therapists and psychiatrists. The reviewers’ job, however, was made difficult by the fact that therapists do  not indicate in their notes when their clients should be seen next, only when they will be seen next. To chart when a client should be seen next creates an accountability on the part of the therapist and the organization to make it happen. And the rare therapist who remarks (in their notes) on the discrepancy between what a client needs and what is available stands on the shaky ground of insurgency.

And so… what was the exciting news my colleague shared with me on that lovely day?

She let me know that the DMHC has mandated that Kaiser mental health clinicians add to each and every chart note a plan for follow-up. This plan will include the clinician’s recommendation for frequency of visits. To me, the inference is clear: the DMHC intends to conduct a follow-up assessment, using an improved technology for chart review. Instead of hiring a panel of clinicians to guess how often someone in a specific clinical situation should have been seen, they’re going to rely upon the treating clinician’s assessment. And, since Kaiser has punished those of us who have put this material in the charts, they are mandating that future encounters include a statement specifying the clinician’s recommendation.

I indicated in my last post that the recent DMHC’s finding that 20% of Northern California clients and 9% in Southern California are having to wait too long for mental health appointments is a serious underestimate of the problem. Now, it seems, the DMHC is developing a strategy to get a more accurate figure. My friend let me know that Santa Rosa managers have yet to come up with a workflow to meet the new mandate about charting. But it sounds like they will have to. And then the data will be (even more) out there.

It may be the Taylor Maid coffee talking, but woo-hoo!


Last week, on February 24, I got two emailed treats.

Jon Brooks from KQED, sent me a link to the Department of Managed Health Care’s just-released “Routine Survey Follow-up Report,” (a follow-up to the DMHC’s March 2013 report). He was curious about my comments which you can read in his article. Later that same day I got an email from Katie Gross, a staffer in US Senator Dianne Feinstein’s San Francisco office. Katie wanted to set up an immediate phone conversation to discuss my experience with Kaiser mental health. I spoke with her the next day, starting a conversation that I hope will end in a federal investigation into the Kaiser Advantage program. More on that in a bit.

But first, I offer a huge “thank you” to all to the folks at the DMHC who participated in the new report. By investigating follow-up services, (defined as any visit after an initial assessment), you’ve opened up a very large and slimy can of worms. Some may say that, considering the enormous pressure from consumers and therapists, you had no choice. But we all have our choices, including quitting our jobs if the going gets too rough. To those of you who stayed at your posts, thanks for going boldly. The report is five giant steps in the right direction.

The primary innovation in the DMHC’s follow-up report is a randomized medical record review. (A description of this review starts on page 18 of the report.) The DMHC hired a team of mental health professionals to review a random sampling of 300 notes charted between September 2012 and September 2013. This review yielded an estimate of how many mental health patients are underserved by the current system: 22% in Northern California and 9% in Southern California (from the report’s chart on page 19). I believe this is a serious underestimate of the problem, though I’m grateful for these numbers. The DMHC has finally started to assess and publicize the breadth of Kaiser’s negligence.

The chart review also produced clear evidence of the intransigence of Kaiser, the corporation, in the face of overwhelming evidence of the need to change. Witness this quotation from a Kaiser psychiatrist who emailed a patient: “’No one ever sees a therapist once a week in the Kaiser Health Plan. Not a covered benefit for the past 20 something years and will not be a benefit in the future.’” (From page 31.) This quotation is from a physician owner of The Permanente Medical Group, stating that no Kaiser member, not even someone with a parity mental health diagnosis, not even someone at grave risk for deterioration and suicide, no one gets weekly individual care from us. Furthermore, this psychiatrist taunts, this will never, ever change. (So quit asking.)


It didn’t take a very large sampling of chart notes (300 charts reviewed) to reveal the corporate culture’s defiant stance toward parity laws. Nor did it take a large sample to reveal the breadth of the service gap resulting from physicians’ we’re-above-the-law position. Consider: “Case #B23: A sexual assault victim…diagnosed with post-traumatic stress disorder (PTSD) and major depression…. an appointment with a Plan therapist was scheduled five months after she was first seen.” (From page 31.) Or: “Case#R21: A child was brought in by her father due to the child’s aggressive behaviors, sexualized behaviors and significant behavioral problems in both the home and school environment… the child was not seen for therapy until seven weeks [after the initial assessment].” (On page 24.)

SO! The DMHC is starting to operationalize “timely care” in a manner that holds Kaiser more accountable. They’re also getting more precise about the health codes they’re citing to justify their increasing level of scrutiny. I wonder, along with you, what kind of fines will follow this report. (A separate arm of State government is responsible for levying the fines.) I wonder, too, if the fines will be suspended for a year or so, giving Kaiser the opportunity to restructure meaningfully. That’s what I would hope. A billion dollar fine, suspended, would possibly do the trick. This is a perfectly reasonable figure, since it will cost hundreds of millions of dollars in therapist salaries to approach the mandate of parity law. The fine must be greater than the cost of change to be effective at promoting change.

Now that the State has stepped up its game, it’s time for the Feds to follow suit, focusing on Medicare and Medicaid’s slice of the Kaiser membership pie.

For years, a significant portion of Kaiser members, including those with mental illness, have been funded by Medicare, under the Kaiser Advantage program. Since January 2014, the Affordable Care Act added another portion of publically-subsidized members to Kaiser, these funded by Medicaid (MediCal in California). Throughout, Kaiser has been given a complete pass on how they deliver mental health services under these entitlement programs. It’s been four years since Kaiser therapists published their white paper about the serious deficiencies in access to mental health care; and there has yet to be a comprehensive audit of Medicare’s mental health services.

Here’s what I am going to urge Senator Feinstein do, on behalf of federal taxpayers and Medicare and Medicaid recipients being denied mental health care on a daily basis. (1) Request that the Centers for Medicare and Medicaid Services (CMS) conduct an audit of mental health services delivered to Medicare and Medicaid recipients, and publish their results. And (2), sponsor an investigation into how Kaiser has, to this point, gotten away with defying federal parity laws.

I can only hope the Senator seizes this opportunity.